Chiropractic Adjustment Consent Form

Patient Information

Full Name Date of Birth Address Phone Number

Consent for Chiropractic Adjustment

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy, on me (or on the patient named above, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic and support staff.

I have been informed about the risks and benefits of chiropractic treatment.

All my questions regarding procedures have been answered to my satisfaction.

Health History

Please list any existing medical conditions or previous injuries Current Medications Allergies

Consent & Signature

Patient/Guardian Signature

Date

Doctor's Name